Concussion Management and Treatment
For patients with concussion, management should include an initial period of 24-48 hours of relative rest followed by a graded return to activity protocol, with targeted interventions for specific symptoms including graded physical exercise, vestibular rehabilitation, manual therapy, psychological treatment, and vision therapy as needed. 1
Initial Assessment and Management
- Concussion is a clinical diagnosis based on history of mechanical force to the head and presence of symptoms such as confusion, disorientation, or transient neurological abnormalities 1
- Remove from activity immediately if concussion is suspected, with no same-day return to play 1
- Implement 24-48 hours of relative rest (avoiding strict bed rest and high-intensity physical activity) 1
- Assess all five concussion subtypes:
- Cognitive
- Ocular-motor
- Headache/migraine
- Vestibular
- Anxiety/mood 1
Symptom Management
- Headache management: Use acetaminophen as first-line treatment; avoid other medications unless specifically recommended by a physician 1
- Pain management: Acetaminophen (1000 mg) or ibuprofen (400 mg) can be used for post-concussion headaches with careful monitoring for analgesic overuse 1
- Medication cautions: Avoid opioids due to high risk of dependency and rebound headaches 1
- Sleep disturbances: Assess and address as part of comprehensive management 1
Return to Activity Protocol
A 5-stage graded return to activity protocol is recommended, with each stage lasting a minimum of 24 hours 1:
| Stage | Activity | Duration |
|---|---|---|
| 1 | Symptom-limited activity | ≥24 hours |
| 2 | Light aerobic exercise | ≥24 hours |
| 3 | Sport-specific exercise | ≥24 hours |
| 4 | Non-contact training drills | ≥24 hours |
| 5 | Full-contact practice | ≥24 hours |
- Progress to next stage only if asymptomatic at current stage
- If symptoms develop during protocol, scale back exertion level to allow maximal activity without triggering symptoms 1
- Require medical clearance from a licensed healthcare provider trained in concussion management before full return to play 1
Targeted Interventions for Persistent Symptoms
For patients with persistent post-concussion symptoms, the following interventions are recommended 2, 1:
- Graded physical exercise: Consider offering graded physical exercise with gradual increase in intensity/complexity over time (minimum 1 time/week for 4 weeks) 2
- Vestibular rehabilitation: For persistent vestibular dysfunction, including otolith manipulating procedures, habituation exercises, and balance training 2
- Manual therapy: Consider offering manual treatment of neck and spine for persistent symptoms 2
- Psychological treatment: Administered by psychologists or clinicians with similar professional background (minimum 1 hour/week for 4 weeks) 2
- Vision therapy: Consider oculomotor vision treatment for persistent visual symptoms 2
- Interdisciplinary coordinated rehabilitation: Treatment provided by health professionals from at least 2 different disciplines for comprehensive management 2
Academic and Cognitive Considerations
- Students require cognitive rest and may need academic accommodations such as reduced workload and extended time for tests 1, 3
- Avoid activities that worsen symptoms during recovery 1
- Provide early information and advice to patients within the first 4 weeks after concussion to prevent persistent symptoms 2
Warning Signs and Follow-up
- Monitor for deteriorating physical or mental status 3
- Seek immediate medical attention for worsening symptoms, repeated vomiting, or increasing confusion 1
- Consider referral to a concussion specialist for complex cases or persistent symptoms 1
Common Pitfalls to Avoid
- Overmedication: Avoid prescribing medications beyond acetaminophen without physician guidance 1
- Premature return to activity: No same-day return to play for diagnosed concussions 1, 3
- Prolonged strict rest: Extended complete rest may worsen outcomes; relative rest for 24-48 hours is preferred 1
- Inconsistent management: Follow evidence-based guidelines rather than varied online resources that may provide conflicting information 2
- Relying solely on neuropsychological testing: Use as part of comprehensive management strategy, not in isolation 1, 3
By following this structured approach to concussion management, healthcare providers can optimize recovery, minimize complications, and improve outcomes for patients with concussion.